The problems with clinical trials of CAM: a case of wholly holey socks?
A lot of hot air has been expended on homeopathy’s apparent inability to “prove” itself in clinical trials. Many people, many of whom call themselves scientists, seem only to need this fact, plus the therapy’s apparent implausibility, to jump to the conclusion the whole thing is nonsense on stilts, and work themselves up into lathers of righteous indignation about the fact that it continues to be practiced. I’ve gone into this a couple of times in the comments to posts on this blog, but this question really does deserve detailed examination, because the issue is not at all as simple as it might seem.
The presupposition of clinical trials is that there is a stable, locally active cause that is only active in the treatment group, irrespective of blinding and the circumstances of the trial or any changed clinical context as a result of the trial. In plain English, this means that the whole basis of clinical trials is predicated on the assumption that the bulk of the treatment effect resides in the physical substance that’s being trialed. It’s a localist hypothesis, proceeding — in homeopathy’s case — from the following logic:
The localist hypothesis of homeopathy is intuitively appealing, simple, and the most straightforward. It presupposes that:
1. Homeopathy works; we know this from clinical practice. This is conceded as a heuristic starting point.
2. If homeopathy works, it cannot be molecules that are the active principle, because at high homeopathic potencies they are statistically too few to be biologically active. This is a logical extrapolation from the known body of biomolecular knowledge.
3. If molecules are not the active principle, it must be something else that is fixed to or in the remedy, and hidden from ordinary analysis for lack of sufficiently sensitive instruments, or theory, or both.
It is a localist hypothesis because it presumes the active principle has to be a local resident to the remedy. It is construed as residing in the material substance.Walach, H. Reinventing the Wheel Will Not Make It Rounder: Controlled Trials of Homeopathy Reconsidered. Journal of Alternative and Complementary Medicine.,Vol 9, No 1, 2003, pp7–13
There’s actually no logical reason why this should be so. Think about it. The rationale behind the assumption is based on a habitual way of thinking arising from acclimation to the parameters of the pharmaceutical model of intervention. Pharmaceutical interventions are based on the mid to high dose ranges of the dose-response curve. Even allowing for the Arndt-Schulz law (now renamed hormesis), homeopathic remedies are clearly right off that scale. Why should we then presume they behave in the same way? And can be tested accordingly?
Experienced homeopathic researchers have made exactly this point:
Imagine the following situation as depicted in the figure: Let there be two treatments x and y for the same condition, say chronic pain. Let there be two placebo controlled RCTs with comparable patient populations. In every one of these trials we will have measurement artefacts caused by unreliability of measures; let them be equal in all groups. In every one of these trials, we will also have regression to the mean as a statistical artefact and as a result of the natural course of the disease studied; some patients will improve regardless of the treatment applied. Then there will be nonspecific treatment effects: Patients expect to get better when treated, especially in a trial. Hope will work against the general demoralization caused by disease. The attention of doctors and nurses within the context of a trial and perhaps the special attention paid to patients within the context of a particular CAM intervention such as homeopathy, healing, or acupuncture, will also contribute to the nonspecific part of improvement. Let us not forget that a treatment that can help patients to understand their suffering by providing an explanation, a common explanatory myth, is a therapeutic factor, too (Frank, 1989). And then there will be specific factors of treatment. Let us assume that treatment y is specifically effective. Its specific efficacy will be 20%, which, in a trial that is adequately powered, will be significant. Thus, everybody will conclude: Treatment y is an effective treatment for chronic pain. Treatment x only has 10% specific efficacy and let us assume that studies of treatment x are generally underpowered to find this effect. Everybody will conclude: Treatment x is an ineffective treatment for chronic pain. What usually is overlooked is the fact that the nonspecific treatment effects of treatment x are much larger. In the thought experiment, I have chosen them to be 30% for treatment x. For treatment y, they would only be 5%. In such a case treatment x, although overall much more powerful with 70% of patients potentially benefitting from it by virtue of its strong nonspecific effects, would be neglected in favor of treatment y, with 55% of patients benefitting from it, because y has a stronger specific treatment effect.
I maintain that this situation is frequently true for CAM therapies. Studies are often underpowered, eg., for acupuncture, and thus potential specific effects are overlooked. The conclusion of reviewers and the educated public then is the verdict “inconclusive evidence” (Ezzo, et al., 2001), and the political consequence, as just happened in Germany, is the decision to not include acupuncture in the scheme for public reimbursement, because the evidence for specific efficacy is inconclusive (Bundesausschuss Ärzte und Krankenkassen, 2001). However, nobody pays attention to the fact that perhaps the magnitude of nonspecific effects makes a treatment effective and not the specific effects. An even more complicated situation can arise when the circumstances of a trial, such as blinding and changing the natural flow of patient–doctor interaction and treatment sequences, change the context of a treatment dramatically and thus alter the potential nonspecific effects in a detrimental way. This can happen in blinded trials of homeopathy, in which insecurity arises from the blinding of doctors, and also in trials of acupuncture, when blinding procedures make it necessary that the doctor who is taking the case and making the assessment is different from the person who is administering the treatment. In all such cases, trials may alter the context of a treatment and thus diminish potent nonspecific factors and thereby underestimate effectiveness.
Walach, H. The Efficacy Paradox in Randomized Controlled Trials of CAM and Elsewhere: Beware of the Placebo Trap. Journal of Alternative and Complementary Medicine, Vol 7, No 3, 2001, pp213-218
This thought experiment of Walach’s models the experience with testing homeopathy and other CAM therapies very well. Data from clinical studies consistently suggest a positive treatment effect of around 70% for homeopathy, yet repeated attempts to replicate these results in controlled trials have failed. It therefore becomes necessary to explain this discrepancy, rather than assume clinical results, especially in such large cohort studies as have been undertaken, can be put down to such notions as “bias”, “regression to mean” and “placebo response”.
It still remains, as Kate Chatfield has remarked:
… if homeopaths can facilitate a placebo-induced healing response in over 70% of people who visit them, many of whom have previously not been helped by various types of allopathic intervention, then surely homeopaths should be highly revered and re-labelled ‘miracle workers’.
Chatfield, K. In Pursuit of Evidence.
As I’ve argued repeatedly, the phenomenon that is homeopathy can’t simply be written off. We need to re-examine the assumptions underlying trial design and look at other ways of satisfactorily evidencing efficacy.
Tags: CAM, clinical trials, evidence, evidence-based medicine, Homeopathy, placebo, Walach
December 26, 2007 at 8:02 pm
“Homeopathy works; we know this from clinical practice.”
If you accept this, then why bother with trials at all? A trial won’t tell you anything you don’t already ‘know’, and open-minded sceptics won’t accept the results of any trial based on a closed-minded, a priori assumption like this.
December 27, 2007 at 11:39 am
I notice, M, that you completely fail to address any of the closed-minded, a priori assumptions that I singled out as operating in assessments of the clinical trial data!
Walach states “This is conceded as a heuristic starting point.” In other words, there’s a large body of evidence backing up the assumption. However, your assessment of the results of homeopathic clinical trials is based on an assumption for which there is no evidence (ie. that the entire therapeutic effect resides in the remedy).
Isn’t that just a tad hypocritical of you?
December 30, 2007 at 7:09 pm
The 70% figure is a nonsense and Chatfield ought to know this. You give no references, but I guess that this is from the Bristol study. The problem is that this was a totally uncontrolled study and so we do not know what the base line is. To say that even this 70% figure is due to placebo would be silly. This study just reflects the number of people who completed a questionnaire that say that they are now better. We do not know who died, who were too ill to complete the questionnaire, who got better anyway, who were taking other treatments and so on. This has been spelt out to homeopaths repeatedly. To continue to use this figure looks like dishonesty.
January 1, 2008 at 7:28 pm
The 70% figure is one that comes up repeatedly in the various studies of homeopathy in clinical applications, not just from the Bristol study. None of these studies test homeopathy in isolation. That’s not their purpose. They do, however, log substantial and sustained improvements in long-standing chronic complaints suffered by patients who had, until adding homeopathy to the range of treatments they were receiving, experienced no improvement in their health. They can show such effects to be superior to what would be predicted by regression to mean, that there are corresponding reductions in use of conventional interventions, and that belief in homeopathy has only minimal impact on outcomes (Witt, Claudia M, Lüdtke, Rainer, Baur, Roland, and Willich, Stefan N. Homeopathic medical practice: Long-term results of a cohort study with 3981 patients. BMC Public Health 2005, 5:115).
Homeopaths have also spelled out to you repeatedly the reasons why DBRCTs are unsuitable tools for evaluating individualised CAM therapies. To continue to ignore these arguments and pretend that the methodology is beyond question looks like dishonesty to me.
January 2, 2008 at 3:31 pm
The study you cite does not mention a 70% figure or anything close. The study also makes no methodological assessment of measuring what would be “predicted by regression to mean” and so you can draw no conclusions. What it does conclude from what I see is that homeopathy has no effect on adolescents(!!!) and “Younger age and more severe disease at baseline were factors predictive of better therapeutic successes” - which is exactly what a ‘regression to mean’ model of homeopathy would predict.
And the reason that I still think DBRCTs are a reasonable test of homeopathy is that no one has spelled out a good reason. Individualisation? - No. you can still individualise all you like and do a RCT. Holistic? No, take whatever holistic measures you like? Quantum Entanglement? - Utter bullshit - no one mentioning this even knows what it means.” The only dishonesty comes from those who keep trotting out the same old excuses about not testing homeopathy.
January 3, 2008 at 5:51 pm
There’s a notable absence of any supporting detail in your arguments, Andy. Would you care to spell out exactly why you believe that to be the case? If you have an idea of a successful trial design to assess the efficacy of homeopathy, is homeopathic treatment to be provided in a clinically typical methodology? How will you deal with the lack of homogeneity presented by individualised treatment? Will the conditions you select to include in the trial be according to biomedical or homeopathic diagnoses? Is the fate of homeopathy in the study to be based on the prescribing skills of a single homeopath or of multiple well-qualified homeopaths? How will you quantify the impact of the homeopaths’ confidence in their remedy selections and how will you separate out any measure of their success from any effect of the remedies they prescribe? Will you allow for reassessment of prescriptions after an initial response period? How will you treat those randomly allocated to placebo? If subjects are to go through the same consultation procedure as those allocated to verum and if the homeopath is to be blinded as well, how will you control for the impact of the consultation and the homeopath’s decision on what remedy they should receive? If this is a valid component of successful treatment, how will you separate it from the response to placebo, and how will you decide on whether or not the therapy is effective? How will you measure response? Will you have typical global and multiple local homeopathic outcomes systematically assessed in the study? ie. ecological validity? Etc, etc etc …
It’s all very well to make broad-brush assumptions about the ability of trials to test therapies like homeopathy, but when you get down to the detail it’s not so simple and those assumptions that seem so rock solid from a distance turn out not to be so at all close up.
The fact of the situation is that the present evidence base for homeopathy is equivocal and reproducibility is an issue. But nonreproducibility merely indicates that not all critical factors are known or adequately controlled for, which is what homeopathic researchers keep on saying. If the therapy really had nothing going for it, then there would be no results showing effect beyond placebo. That isn’t the case. The data don’t allow a conclusive decision to be made either way. Ergo more research needs to be done to ascertain exactly what’s going on.
Nonsense! Do you imagine that physicists have some sort of a monopoly on the use and interpretation of this metaphor? Because that’s all it is. That’s all any scientific theory is. Analogy, metaphor, models, maps. Heavily filtered as they are through the subjective experience of individual awareness, they amount to little more than consensus maps of common experience, no matter how much ‘reality’ they seem to have, how much predictability they confer, how much you might want to ignore the vast amount of subjectivity built into any of them, or how much you’ve mistaken them for reality itself. Quantum entanglement isn’t really ‘real’. It’s a metaphor used to model “spukhafte Fernwirkung”, which is observed frequently enough in contexts other than particle physics to have made the metaphor potentially useful outside of those applications.
Careful, Andy. Your karma might just run over your dogma one of these days. No amount of repeating the same assertions is getting to grips with the fundamental issues here. Your logic is looking increasingly circular, and attempting to brand all homeopaths ‘dishonest’ because they say there are issues with using DBRCTs to “prove” complex individualised therapies sounds to me little more than a clumsy and patently insupportable ad hoc hypothesis.
January 3, 2008 at 7:30 pm
Laughing perhaps I could suggest a DBRCT to study the efficacy of homeopathy that would take into account for your concerns about correct methodology.
1) Take a large enough sample of the population to give statistical significance. These volunteers would be healthy at the start of the trial. The number would also need to be big enough for any dropouts to not spoil the significance of the result.
2) These people then each visit a homeopath for a certain period (1 year, 2 years, 5 years, ?). The same homeopath would not have to be used by each patient. This would allow the effects of practitioner skill to be accounted for.
3) Following each consultation the homeopaths can prescribe whatever remedy/potency they believe would be beneficial for any ailments the patients may have at the time
4) The patients are split into active/placebo groups and, following each consultation, the patients take their prescriptions to a homeopathic dispensary, where they are given either their remedy or a placebo depending on the group they’re in.
5) Throughout the study all patients submit questionnaires to assess how they feel their general health is. More objective measures of health can also be assessed (e.g. blood pressure, blood tests, whatever you feel is necessary).
6) At the end of the study the data collected are examined to find any significant improvements in the general health of the active group.
I, and most skeptics, would expect that no significance between the two groups. However, if a difference could be found, this would be a significant result for homeopathy. Are their any methodological problems you can see in this protocol?
January 3, 2008 at 8:37 pm
Socks, if a well designed RCT came out showing a positive result for homeopathy would you be telling your colleagues:
“no no this doesn’t show homeopathy works, you didn’t deal with the lack of homogeneity presented by individualised treatment? you didn’t quantify the impact of the homeopaths’ confidence in their remedy selections… go back and get me more anecdotes damit!”
or would you be trumping the paper round the blogosphere conveniently forgeting about your problems with RCTs
as far as I can see the only problem you have with them is they don’t give you the result you want. perhaps you need to face the fact that it is the homeopathy that isn’t working not the testing.
January 3, 2008 at 11:47 pm
John R, this trial design still assumes a localist hypothesis — ie. that the greatest effect (and by implication the “proof” of the therapy) is carried by the little sugar pill the trial subjects pick up from the pharmacy. There’s no evidence for presuming that this is a valid assumption. (After all, there’s nothing in them is there?!)
It’s the very failure of homeopathy to produce consistent results with similar trial designs to this that have led researchers to question the whole suitability of DBRCTs as a tool for evaluating the therapy.
If, as fits my own frequent observations and those of many other homeopaths, the act of correct remedy selection by the homeopath can have an immediate impact on the patient that is only enhanced by the later administration of the little sugar pill, rather than being necessarily wholly dependent on it, then we are dealing with what is effectively a distributed phenomenon and a parapsychological element in the therapy that’s not easy to quantify and control for. CAM therapies are holistic in more than one sense.
This hypothesis would predict that there would be a large number of ‘placebo’ responders in conventional trial designs, some of which would have surprising strength (which is, in fact, often the case), and that testing remedies on the basis of a localist hypothesis would produce equivocal results (which it does).
Ross, don’t judge others by your own standards. My reservations about RCTs remain regardless of the results they produce. Neither am I so stupid as to believe that one trial or even one meta-analysis proves anything … unlike certain medical journals. Positive results are only useful insofar as they serve to emphasise — particularly to sceptics or pseudosceptics (ie. disbelievers) — that the trial data is equivocal rather than conclusively negative. That’s been my position since starting this blog. I don’t believe homeopathy is “provable” through RCTs because they’re a tool designed to evaluate therapeutic interventions that conform to the assumptions of the biomedical model and most CAM therapies don’t conform to those assumptions. Just look at the trial data! Half of it represents a bastardisation of homeopathy in order to try and shoehorn it into the conceptual constraints and ‘quality criteria’ of RCTs. They don’t (and can’t) take account of the myriad subtle and non-specific effects of CAM therapies which individually amount to little but collectively amount to an effective intervention. I believe evidence of efficacy is to be found in a comprehensive assessment of all evidence, both quantitative and qualitative, pertaining to a given therapy, and that’s a position I’ve consistently maintained as well.
Perhaps you need to face the fact that the biomedical model doesn’t know the half of it when it comes to healing people of their illnesses, and that the perceptual schizophrenia that operates within this viewpoint is incongruent with our experience of life.
January 4, 2008 at 12:22 am
Let’s answer these questions…
If you have an idea of a successful trial design to assess the efficacy of homeopathy, is homeopathic treatment to be provided in a clinically typical methodology?
Yes
How will you deal with the lack of homogeneity presented by individualised treatment?
Individualise as much as you like - the trial is randomised and blinded at the point of dispensary.
Will the conditions you select to include in the trial be according to biomedical or homeopathic diagnoses?
Choose whatever conditions you like. We can choose generic endpoints, like how patients feel about their health - any ‘holistic’ measure you like.
Is the fate of homeopathy in the study to be based on the prescribing skills of a single homeopath or of multiple well-qualified homeopaths?
Don’t care - whatever is best for maximising the chance of success for the homeopaths.
How will you quantify the impact of the homeopaths’ confidence in their remedy selections and how will you separate out any measure of their success from any effect of the remedies they prescribe?
Is this important? We want to see if patients feel better.
Will you allow for reassessment of prescriptions after an initial response period?
Yes. If homeopathy is working we should see more reassessments in the placebo group.
How will you treat those randomly allocated to placebo?
Exactly the same as those thinking they are getting homeopathic remedies. That is the point of blinding.
If subjects are to go through the same consultation procedure as those allocated to verum and if the homeopath is to be blinded as well, how will you control for the impact of the consultation and the homeopath’s decision on what remedy they should receive?
Let the homeopath prescribe what they like. It is at the point of dispensary that randomisation takes place.
If this is a valid component of successful treatment, how will you separate it from the response to placebo, and how will you decide on whether or not the therapy is effective?
Those with the real therapy will score better than those on placebo.
How will you measure response?
In whatever way you think is appropriate for a homeopathic consultation. How does a homeopath judge success?
Will you have typical global and multiple local homeopathic outcomes systematically assessed in the study?
If you wish.
There appears to be an assumption that DBRCTs need to test one remedy at a time. That is not true. We are testing the impact of the potentized pills on the process. Does the act of homeopathic prescription make any difference to outcomes? That is what we are testing.
Nonsense! Do you imagine that physicists have some sort of a monopoly on the use and interpretation of this metaphor? Because that’s all it is. That’s all any scientific theory is. Analogy, metaphor, models, maps.
I am afraid that you are entirely wrong here. Quantum theory is not a metaphor.
A metaphor is a figure of speech in which an expression is used to refer to something that it does not literally denote in order to suggest a similarity. Metaphors are used well to add clarity to unfamiliar concepts by showing similar attributes between different conceptual elements.
Quantum mechanics is not a metaphor. It depends on a mathematical formulation that allows precise prediction of the behaviour of physical systems. Metaphors can never do this. Quantum mechanics is probablty the most successful theory ever devised in that its predictive and explanatory powers far surpass any other field of study. If you are talking about quantum mechanics and not using mathematics to make predictions about the world then you are not doing quantum mechanics. Milgrom et al are not doing quantum mechanics. They are confusing metaphor with theory.
Confusion about metaphor is a trait I find regularly in arts trained graduates. They fail to see the inherent limitations of metaphor and start overplaying their importance. Quantum entanglement is as real as we can say anything is. It has been observed and tested and we have a mathematical approach to describe when it should be observable. Einstein came up with the phrase “spukhafte Fernwirkung” to show his uneasiness with the predictions of QM. Einstein was wrong on this occasion. Our understanding of entanglement show us that there can be no possibility of a entanglement effect in the prescribing practices of homeopaths. The idea is utterly preposterous.
January 4, 2008 at 12:32 am
Laughing I realise that any effects noticed by homeopaths are unlikely to be solely due to the pill. This is the point many skeptics make repeatedly. In this respect homeopathy is no different from councelling. This explains why homeopaths often report success in areas such as sleep disorders, stress, grief and mild depression. These patients will obviously repond positively to the sympathetic ear of a homeopath. This is one of the reasons people often ask homeopaths to cite instances of non-self-limiting conditions reponding to homeopathy.
The only thing that distinguishes homeopathy from councelling is the administration of sugar pills. You state that the protocol I outlined is unsuitable as the pills only enhance the effect. On the contary the protocol will be able to judge if the pills have any effect, as this would make the groups distinguishable. To state that the failure of homeopathy to pass such tests suggests a failure of DBRCTs is nonsense. Either the pills have an effect, and the tests will show this, or they have none what so ever. If these tests are failed then the whole basis of homeopathy (like cures like, high potency at high dilution, with succussion) is shown to be a sham.
January 4, 2008 at 4:52 pm
Sigh … it’s going to be a long one …
Neither of you can see it, can you? I’ve used this analogy before, but its like two fish swimming about in the sea and one saying to the other “so what’s this ocean you keep talking about then?”
Looking out from your own personal vision of reality, it’s very easy to spot the metaphorical nature of theoretical constructs you don’t subscribe to — the more ‘alien’ they are, the easier it is to see — how the logic appears circular, the conclusions predicated on the initial assumptions, even how there’s a degree to which proponents appear able to enrol external events into their own personal feedback system as well as employing selective observation in that regard. You roll about laughing, brand them as stupid and deluded, congratulate yourself for being intelligent enough to see the “truth”, and heap derision in their general direction. But what you don’t see is that you’re doing exactly the same thing, that this is how all thought systems function, and that you’ve just caught a glimpse of a ‘reality’ that’s more real than you know.
The initial assumptions which are axiomatic to your view of life are so taken for granted you’re scarcely even aware of them, let alone inclined to question them. But this doesn’t change the fact that they’re assumptions, and that they’re questionable. Everything that follows on from them merely confirms them. All proof systems devised under such assumptions simply end up demonstrating the assumptions. It’s not possible for them to do otherwise. ALL logical and formal systems beyond the most basic, all theories and hypotheses, are inherently self-referential. ALL can be contested on the grounds that their initial assumptions are questionable. ALL are ultimately subjective, because we can only apprehend the nature of existence filtered through limited personal human subjective experience of it. ALL are consequently no more and no less than metaphor, analogy, models, maps.
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John R:
Homeopathy is not counselling. Just because homeopathic consultations can last as long as a counselling session and provide some benefit to a patient because their personal reality is being validated in the process doesn’t make them equivalent. The two processes are in all other respects quite different and produce quite different effects. If the remedy for someone’s state is blazingly obvious, no consultation is required. This doesn’t detract from the response. Children and animals are, if anything, aggravated by long consultations, but that doesn’t change the nature of their response either. Your hypothesis is hence demonstrably incoherent with observational data.
In my answer to Humber on the previous thread, I’ve set out in a lot more detail why it is that DBRCTs are unsuitable tools for evaluating therapies that are predicated on different assumptions to the ones underlying the biomedical model.
There’s not a lot of point in continuing to go round in circles here — your reasoning that homeopathy is a sham can be boiled down to the circular logic unique to a thought system that has created an arbitrary, simplistic and rigid perceptual dichotomy according to the dogma that anything “objective” is “real”, anything “subjective” is “unreal” (regardless of the actual weighting of verifiable observations and coherent modelling within those definitions, and notwithstanding the number of double-standards evident). So however we formulate this, because homeopathy is predicated on, and operates largely within subjective realms of experience, it’s actually impossible (by virtue of your initial assumptions) for you to regard homeopathy as anything other than illusory for as long as you hold the premises of that perceptual dichotomy to be “true”. Does that mean homeopathy is illusory just because your personal subjective experience of this metaphorical construct is coherent and “real”? Not at all, because subjective experience is unreliable, because your initial assumptions are open to serious question, your logical formulations inconsistent and inaccurate, your observations demonstrably selective, and much of the coherence and reality you personally experience appears self-referential and self-maintaining.
Exactly the same criticisms apply to my position, so where does that leave us? I would say that our respective assumptions, opinions, reasoning and convictions have no less and no more fundamental reality than each other’s. That doesn’t mean either is “untrue”, just that the human experience of reality is as much subjective as it is objective, and that the more overtly subjective aspects have no less fundamental “reality”. Hence therapies predicated on subjective experience can produce no less “real” results than those based on relatively objectified axioms.
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Andy:
Interesting … your earlier comments about homeopaths needing certainty in their lives are now looking decidedly self-referential. BTW I’m not an arts graduate (studied biology as it happens), and I’m very aware of the nature of metaphor. Quantum mechanics is quite beautiful and yes, I’m aware of its mathematical precision. This doesn’t make it any less of a metaphor. As Stephen Hawking said some years ago, “Although quantum mechanics has been around for nearly 70 years, it is still not generally understood or appreciated, even by those that use it to do calculations. Yet it should concern us all, because it is a completely different picture of the physical universe, and of reality itself.” Indeed. Yet much of science, particularly biomedical science, still behaves as if absolute objectivity, internal consistency, linear logic and deterministic predictabiliy are cornerstones of the fundamental “reality” under consideration. Hawking carries on in the same lecture to say, “Many scientists are like Einstein, in that they have a deep emotional attachment to determinism. Unlike Einstein, they have accepted the reduction in our ability to predict that quantum theory brought about. But that was far enough. [...] I feel these scientists have not learnt the lesson of history. The universe does not behave according to our pre-conceived ideas. It continues to surprise us.”
You’re absolutely correct when you say “Quantum entanglement is as real as we can say anything is” but the emphasis here HAS to be on the latter part of your sentence. This is what it all boils down to. Metaphors have all sorts of uses and there is no logical reason why they should be restricted to their areas of greatest precision. Precision is as much a function of a limited number of variables as it is of anything (already highlighted in discussions about RCTs), and in particle physics you’re not dealing with an awful lot of variables. Look at it from another angle: if a theory has a high degree of coherence with fundamental reality, then the more of fundamental reality it should be capable of modelling. Hence Hawking’s comments, and why quantum mechanics as analogy has found its way into consciousness theory, parapsychological research, CAM therapies and other areas of subjective experience that so-called “hard” science tries to invalidate or deny as a result of its perceptual schizophrenia.
You can, of course, argue ad nauseam about whether the concept should still be called “quantum mechanics”. Homeopaths have exactly the same problem in defining exactly what is and is not “homeopathy” … an inevitable problem of attempting to encapsulate and objectify processes that operate on many different levels and in many different ways. It’s also invariably the case that definitions put forward coincide with the personal definitions and subjective experience of the person putting the suggestion forward who, of course, thinks that they’re “right” and everyone else is “wrong”. Whereupon everyone involved expends vast amounts of time and energy in arguing about it, each believing they and those with tolerably similar outlooks are “right”, and everyone else is “wrong”. Yawn …
You say “Our understanding of entanglement show us that there can be no possibility of a entanglement effect in the prescribing practices of homeopaths.” Here the emphasis has to be on the first two words of your statement, because your understanding of entanglement can’t adequately allow or control for the role of consciousness in creating what you are observing. The act of observation requires consciousness, even if carried out indirectly via machines, so consciousness (and all the subjectivity it carries with it) is inextricably bound up in what you’re doing, whatever you’re doing. If the conscious expectation of observing quantum entanglement is what creates entangled particles to begin with, then you have nothing more than a self-fulfilling prophecy. And if, as seems likely to those working in these areas, CAM therapies act largely through analogous mechanisms in consciousness, then observations resembling quantum entanglement (“spooky action at a distance” or whatever woo you want to call it) are entirely natural.
If quantum entanglement is as close as we get to fundamental reality and quantum entanglement is created through consciousness, then does that mean that consciousness is the fundamental reality? There’s an awful lot of people right now arriving at this very conclusion via all sorts of different academic and experiential routes. Many physicists (Capra, Wolf, Goswami just for starters) seem to think so too. Not to mention that eastern religious philosophy has been saying exactly this for millennia. Personally I think this hypothesis has a lot going for it and is capable of modelling all manner of anomalous observations that so far have been designated either “invalid”, “impossible” or “fabrication” by some sections of the community, as well as synthesising much of existing areas of knowledge.
Whatever you might think of that, it remains the case that fundamental reality supports all of us in our subjective constructs of it. It obligingly serves up all the “proof” we each need to maintain ourselves solidly in our opinions for as long as we continue to hold them, no matter how “preposterous” others might feel those to be. And if we pay more attention to the anomalies and trade our models in for different ones, then reality dutifully confirms us in those beliefs instead. Nobody gets struck down by lightning because their views are “wrong” or untenable, only by other humans who think they alone are “right” and have the right to enforce their view on others. So perhaps the message here is that unity in diversity, rather than uniformity, is the way to go. This is what CAM therapists have been arguing for a long time — that there is no one way of looking at things and there are many valid ways to help people regain their health, not all of them “provable” within the limited constraints of an objectified metaphor like biomedicine.
We really do need to stop mistaking the maps for the territory. This is absolutely critical to good science. And it’s essential that we continually engage in exposing and undermining the construction of “knowledge”, right down to its most basic axioms, in order to remain as close as possible to that fundamental reality we seek to describe.
January 4, 2008 at 5:15 pm
Laughing a DBRCT has nothing to do with a biomedical model. It merely looks for differences between two groups. I’ll state the assumptions upon which I think the the protocol I outlined is based:
1) Given a large enough sample of the population, splitting this group in two, in a random manner, will produce two groups that are indistinguishable by any factor you choose to measure.
2) When initiating a single change in the groups any factor affected by this change will cause the groups to become distinguishable.
How does your personal view of reality differ. Do you disagree with either of these assumptions? Do you think that there are other assumptions I have missed?
January 4, 2008 at 5:35 pm
Socks you make this twelvty times more complicated than it needs to be.
You haven’t brought up any problems that couldn’t be addressed in the trial design.
January 4, 2008 at 7:35 pm
Let’s get down to refuting what substance your comment has. At the heart of your claims is that it is valid to extend quantum mechanics to other areas because physics does not ‘own’ quantum mechanics and it is just a metaphor anyway.
Let me give you an example from you own field of biology - evolution. Lots of mad and bad people have used evolution - as a metaphor - and tried to apply it to areas outside of its original remit. Everything from politics, economics and history. Often these uses have resulted in disasters and deaths of millions. This is not because of anything inherently bad within evolutionary theory, but because people have misused it terribly. For evolution to be applicable you need a set of preconditions - inheritance, variation and selective success. Without these things, evolutionary theory cannot apply. Some bad economists have used the metaphor of ’survival of the fittest’ to justify a ’scientific’ theory for policy making. But this is abuse of evolutionary science because in economics there is no good equivalent to inheritance and that also it makes the naturalistic falacy - drawing ethical conclusions from natural facts. Evolution has just become on over-reached metaphor. Misuse of metaphor can have very serious consequences.
The same goes for quantum theory. It is abused by all those who wish to give scientific credence to otherwise irrational, madcap or at least speculative claims. For quantum theory to apply you need to define the time evolving quantum mechanical wave function for the entities under study and this then allows the mathematical calculation of probabilities for the outcomes of experiments. If you cannot do this, then you are on very shaky ground. Typically this only works with systems of a few subatomic particles. Trying to apply QM to two huge mounds of organic goo with one moaning about feeling tired and the other dishing out sugar pills is not going to work.
Or as someone put it more succinctly on the rapid response to Lionel Milgrom’s paper - “The story of Little Red Riding Hood is similarly a metaphor of childhood development, but I would not refer to it as a guide to managing neuroendocrine problems in adolescents. ”
Your lack of understanding of QM shows in your quoting of hawking when he says - “Unlike Einstein, they have accepted the reduction in our ability to predict that quantum theory brought about.” This has nothing to do with the homeopathy question. What Hawking is talking about is the conjugate variable problem. This arises from the uncertainty principle and tells us that if we measure one eigenstate with high precision we can only know the value of the conjugate variable with low precision. It is a common misconception to think QM means that we have to be uncertain about the world - rather that if we desire certainty in one variable, we must accept uncertainty in other values.
And as for you quantum mind speculations - that is all they are. They are not widely accepted at all that consciousness is the primary force that constructs reality around us. It is a rather banal suggestion.
You say “Nobody gets struck down by lightning because their views are “wrong” or untenable”. But that is of course simply wrong. If someone had the mistaken view that thunderstorms were not dangerous and went out flying kites during a storm, their ‘consciousness’ will in no sense protect them from the rather inevitable invasion of an external, objective reality into their soon-to-be-ended and rather daft life. Other people might have told them that their beliefs about storms were “preposterous” and they may have claimed back that “fundamental reality supports all of us in our subjective constructs of it” and that the storm will “obligingly serves up all the proof” needed to confirm its safety. Some friendly local CAM therapist may have supported them in their ‘life-choice’ to object to the patriarchal and corrupted tyranny of meteorologists and physicists and given them a lift to a hilltop whilst reassuring them that there was no proof of the harm of lightning. At least in this village. Reality is not going to “dutifully confirm those beliefs”. No matter how much you protest, and just like the man in the storm found out too late, there is an objective and external reality that is independent of us and the best way we know of understanding it, albeit provisionally and imperfectly, is though the scientific method.
The same goes for the equally dangerous and misguided belief that homeopathy can provide prophylactic protection against malaria. That is either true or false, and a homeopath’s willingness to believe this or make it ‘part of their consciousness’ will make no difference. Since there is no scientific evidence to suggest that this is true and absolutely no reason to think it could ever be true, then anyone still believing this subjects themselves to being caught out to that tireless and unforgiving reality of the lighting strike of an infected mosquito bite.
laughingmysocksoff - in stating such things about the nature of reality, you sound like the wooliest first year undergraduate who has been told about postmodernism and read a bit of Fritjof Capra. All emotionally appealing stuff, but intellectually vacuous. I would expect nothing less from a homeopath.
And as for saying “we really do need to stop mistaking the maps for the territory”. That is exactly what you are guilty of. By using the map of quantum mechanics and applying it to homeopathy you might as well be taking a map of Afghanistan and using it for a cycling holiday in Dorset.
January 5, 2008 at 2:39 pm
laughing, if you were a funding body, how would you decide between two competing therapies? half each, 70/30 depending on who sounds more convincing? How would rule one out and one in?
January 5, 2008 at 6:44 pm
Dig deeper John. The whole basis of assembling 2 large groups of people all suffering from condition A, doing one thing to one group, another thing to the other, and looking for the differences, is predicated on homogeneity. The absolutely phenomenal number of variables at play in all the lives of all the people taking part in a trial can only be regarded as background “noise” if
i) the people are all suffering from the same condition
ii) any changes measured are measured in respect of that condition
iiI) they’re all given identical treatment localised to a single variable
Agreed. But homeopathy doesn’t constitute a “single change”. It’s a complex intervention which introduces many more variables into the equation.
i) people are not seen as suffering from the same condition. Their “background noise” is as important as condition A and is what differentiates between them.
ii) responses are global, not limited to condition A
iii) they’re all given individualised treatment which is not localised to a single variable and is also dependent on the practitioner’s skill in selecting it.
So not only have you blown your critical homogeneity between points i) and ii), you’ve also lost your “single change”. On top of that, you’re comparing 2 groups both of which have some treatment effect running, so you’ve failed even to adequately control your principal variable.
About the only effective way I can see that you might be able to trial homeopathy successfully would be to compare it to dummy intervention as a complete package, by randomising patients to either geniune homeopathic treatment or to a homeopathic-style interview conducted by a non-homeopath plus placebo.
January 5, 2008 at 6:55 pm
Ross, very good minds have been working on addressing these problems through trial design for many years now. It’s just not as simplistic as you plainly see it to be.
See my response to John R above. The salient point is that pharmaceutical RCTs hang on a very fine balance so that the huge number of variables involved can be effectively cancelled out from both sides of the equation. The different way that homeopathy works tips that balance in such a way that the results are no longer clear or reliable.
January 5, 2008 at 7:43 pm
Laughing did you read the protocol I outlined above. It did not involve assembling groups of people suffering from any condition. I stated that the volunteers would be healthy at the start of the trial. The trial doesn’t study any one condition nor any one remedy. It measures homeopathic remedies as a whole. A holistic approach if you like. I also stated that not all volunteers needed to visit the same homeopath so the trial is not based on the skill of any one homeopathic practitioner.
The trial only measures the differences in the health and perceptions of health between the two groups. It is also only the effect of homeopathic remedies that is being assessed in the trial. The effects of consultation and remedy selection would also be the same between the two groups. If homeopathic theory is correct and its remedies have an effect at the end of the trial a difference would be evident between the groups.
You clearly don’t believe such a trial would make the groups distinguishable but have not given any indication of why?
January 5, 2008 at 10:21 pm
Ummm … not quite. At the heart of what I’m saying is that a large degree of subjectivity and self-referential logic is intrinsic to, and inextricable from, absolutely every thought system and every scientific theory mankind has ever come up with. Because of that intrinsic subjectivity (subjectivity being unreliable), all of them are no more than analogies, metaphors, maps, models which attempt to provide some kind of logical framework that’s coherent and congruent with our experience of reality. Because of that intrinsic subjectivity (subjectivity being unreliable), all our assumptions, observations and conclusions are open to question. Because of that intrinsic subjectivity (subjectivity being unreliable), no metaphor is necessarily any more “right” than any other: there’s just varying degrees of congruence in various circumstances. Because of that intrinsic subjectivity (subjectivity being unreliable), the rigid distinctions we make between “objective” (= valid) and “subjective” (= invalid) data are arbitrary and inappropriate.
That’s pretty much the nub of it.
What use individual people put metaphors to is neither here nor there when considering the nature of metaphor itself and is a bit of a red herring in the context of what I was saying. But since you brought it up, how can a metaphor be ‘abused’?!! It doesn’t have a personality or identity to abuse! People, though … people feel abused. People feel abused when metaphors they’ve identified themselves in are not being used in the same ways they use them or in ways they think they ought to be used. People abuse others when a claim of validity for some other metaphor that doesn’t fit into their own personal one feels like some sort of a personal insult. Is that what’s going on here Andy? Thing is though, you’re Andy Lewis. You’re not quantum mechanics, even if you use it as a metaphorical means of exploring your existence and spend your days up to your eyeballs in QM calculations. And you, after all, are using your personal identification in this particular metaphor and the wider metaphorical context it finds itself in to justify making unprovoked attacks on people you’ve never met, who have never harmed you, and who’s services many people value highly, purely because their metaphor doesn’t fit within your own, and because you’ve mistaken your metaphor for reality itself. Some people might take that for an abuse of a metaphor …
This is if you’re using quantum theory quantitatively in systems of very few variables to make very precise predictions (as I mentioned above). But that’s an awfully limited use of a very fine metaphor, and it still doesn’t prevent you using it qualitatively when a logical framework with similar properties appears to be the best metaphor for what you’re observing.
As for my quantum mind speculations, of course they’re speculations! But then the quantum mechanical wave functions required for your calculations exist only in your mind and imagination (I psi with my little eye …). No time loop, no story. No existence. And where does it all start? In your mind. So how can you prove that you defining those time evolving quantum mechanical wave functions to do your calculations hasn’t established a conscious correlation with the entities you’re studying which then … bingo! … do exactly as you’ve predicted they will?
I’m well aware that consciousness theories are not widely accepted … yet. But I don’t agree with you about them being banal. There’s some very exciting work being done in that area by some very able people that I personally find far more stimulating than anything I’ve come across in science for a long time.
I’m perfectly aware of what Hawking was talking about, and I wasn’t using the quote in the way you seem to think I was. Read the sentence that preceded the quote. I said “Yet much of science, particularly biomedical science, still behaves as if absolute objectivity, internal consistency, linear logic and deterministic predictabiliy are cornerstones of the fundamental “reality” under consideration.” The contingency the principles of quantum theory placed on each of these precepts has not been taken on board in biomedicine. The uncertainty principle in fact parallels Gödel’s Incompleteness Theorems which state that with respect to any given formal and consistent mathematical system, either its completeness or its consistency can be proved within its own terms but not both simultaneously, and each only at the expense of the other. You can extrapolate this proof in qualitative terms to show that it’s equally applicable to thought systems. This has implications for the “proof” of any one system, and particularly the proof of one system within the axioms of another, which is a point I’ve been trying to make about trying to prove homeopathy within the assumptions which underly biomedicine and much of mainstream science at this time.
Ah. That old chestnut again. You know, the SoH contacted the BBC Newsnight programme makers directly to ask for their evidence that any of their members had given dangerous or misleading advice to members of the public. They were unable to provide a single example. And Baum’s assertions of an “epidemic of malaria” due to “backpackers…taking homeopathic prophylactics” isn’t supported by evidence either. Malaria cases in this country have fluctuated between 1600 and 2500 per annum during the last 20 years with rarely more that a dozen deaths in any one year, and since 1996 cases have been declining. Hardly an “epidemic”.
I’m not saying belief is going to stop a hungry mosquito from giving you malaria, but neither does that mean you should underestimate the role of the psyche in illness. People in perfect physical health have been known to get sick and die after being told, mistakenly, that they have an incurable disease and only a few months to live.
There seems to be a general tendency here to suppose that because I’m saying the role of consciousness and subjective evidence deserve consideration that I’m arguing that they should somehow have primacy over more objectified assessment. Not at all. You’re the people who deny all validity to subjective experience. I’m arguing for balance: a less rigid and more pragmatic approach to all manner of evidence to build up a comprehensive picture of what any given metaphor has in support of it. It’s an approach which is more congruent with the underlying balance between subjectivity and objectivity that actually informs our observations and rationalisations of our experience. If I have to underline what subjectivity has going for it, and how fundamental it is to everything we do, it’s to say it’s valid and doesn’t deserve total (and arbitrary) exclusion.
Nonsense, Andy. There’s no mistaking the map for the territory here. The map remains a map. The territory remains the territory. I’m saying the qualitative principles of quantum mechanics have the potential to model some of the observations which have been made in respect of homeopathy and many other of the more subtle, holistic therapies. Let’s get one thing straight right away. These effects are not specific to the therapy. They just become more apparent in the context of the therapy because of its level of subtlety and its holistic nature. They’ll be occurring just as much with conventional medicine too, but will be far less obvious to observers who are looking at things in a much more focused and linear way. If you’re giving a patient medication for their arthritic knees, you’re not interested in some apparently irrelevant notion that occurred them in the context of their treatment (and in 6 minutes they’re unlikely to tell you anyway). Homeopaths pay attention to these things, which is how come we notice the patterns and correlations that are evident throughout the entire system, and how the whole organism responds to various stimuli.
January 5, 2008 at 10:35 pm
John, if the volunteers are healthy then what on earth are you treating them for?!! What are you going to prescribe on? How are you going to measure any effect?
This adds nothing to the present body of data. Homeopathic remedies on their own have been tested and tested. There is an effect beyond placebo in a significant majority of trials (before you start meta-analysing them down to a bare handful that meet your “quality” criteria), but it’s not as strong or reliable as you would expect from a pharmaceutical intervention. That’s only to be expected if the localised hypothesis doesn’t obtain (per Walach above).
I’m not sure what you’re trying to say here. You started out by implying this was a protocol to demonstrate the efficacy of the therapy, not the remedies on their own. The whole purpose of my posting on this subject was to show that testing the remedies on their own isn’t going to provide “proof” of the therapy.
January 5, 2008 at 11:13 pm
“by randomising patients to either geniune homeopathic treatment or to a homeopathic-style interview conducted by a non-homeopath plus placebo.”
Aaaaah, I see, I think…
What would happen if, in the course of the genuine homeopathic treatment, the remedy was switched to placebo without any party knowing?
What would the effects on the patient be? Would you expect this group to still perform better than the ’sham’ group, or same?
January 6, 2008 at 1:32 am
By “in the course of the genuine homeopathic treatment” do you mean after initial administration of verum or before?
For the sake of clarity, lets say we have 3 groups. A dummy group (D), a real McCoy group (rM), and the switched group (S). If the switch was made before the initial administration of the remedy, I would expect the difference between rM and S to be similar to that already established in trials of individualised homeopathy between rM and placebo, and the D group significantly behind that. If the switch occurred after the first dose of the remedy, I would expect the results of the rM and S groups to be much closer, and still significantly better than D.
January 6, 2008 at 12:08 pm
“By “in the course of the genuine homeopathic treatment” do you mean after initial administration of verum or before?”
The switch would be made at exactly the same time as the real rememdy *would* have been administered. The point is this: only by switching in this manner can we see most clearly what effect the remedy has on the homeopathic consultation.
“I would expect the difference between rM and S to be similar to that already established in trials of individualised homeopathy between rM and placebo”
Ergo the homeopathic remedy does nothing.
_____
Your trial with the dummy group is a big gamble:
If the dummy group failed, it would be easy to argue that the placebo effect was lessened becuase of the faux practitioner.
If the dummy group performed as well as Rm or S you would be forced to accept homepathy does not work.
January 6, 2008 at 3:18 pm
John, if the volunteers are healthy then what on earth are you treating them for?!! What are you going to prescribe on? How are you going to measure any effect?
Please read my protocol again. It is a long term study that tests the effect homeopathic remedies have on the health of the volunteers. While they are healthy at the beginning of the trial during its course they would develop a variety of ailments that would be treated homeopathically, but with either the administration of real remedies or placeboes depending on their group.
Certain illnesses that require imediate treatment (e.g. cancer) would result in the volunteers dropping out of the trial immediately for ethical reasons. The likelyhood of these type of dropouts would be similar for both groups. There may also be other dropouts from people with less serious complaints. I would postulate that these dropouts would also be equally likely, but if homeopathic remedies have any effect, the dropouts amongst those recieving real remedies should be less. The real test of the trial would, however, be in the health of those who lasted the whole trial.
I’m not sure what you’re trying to say here. You started out by implying this was a protocol to demonstrate the efficacy of the therapy, not the remedies on their own. The whole purpose of my posting on this subject was to show that testing the remedies on their own isn’t going to provide “proof” of the therapy.
Alright I wasn’t clear in this the protocol is testing just the remedy. Your point in the original post is that there is no reason to believe that any positive effect of homeopathy is in the remedy. Your quote from Walach:
If molecules are not the active principle, it must be something else that is fixed to or in the remedy, and hidden from ordinary analysis for lack of sufficiently sensitive instruments, or theory, or both.
It is a localist hypothesis because it presumes the active principle has to be a local resident to the remedy. It is construed as residing in the material substance.
So are you saying that the art of homeopathy ends with remedy selection and actually giving the patient the remedy and them ingesting it does not have an effect. If it does have an effect I’ll accept your hypothesis that does not form the complete therapy, but if it has any effect it will show up in my trial.
This adds nothing to the present body of data. Homeopathic remedies on their own have been tested and tested. There is an effect beyond placebo in a significant majority of trials (before you start meta-analysing them down to a bare handful that meet your “quality” criteria), but it’s not as strong or reliable as you would expect from a pharmaceutical intervention. That’s only to be expected if the localised hypothesis doesn’t obtain (per Walach above).
Firstly I’d reject your first point. If homeopathic remedies were distinguishable in this trial it certainly would add to the present body of data. Secondly Walach’s objections (the bit after the graph in your post) are irrelevent. We’re not testing a certain homeopathic remedy but homeopathic remedies as a whole. Because of this the underpowering effect would be absent as if one remedy doesn’t work another can be used. I think Walach’s point is that a remedy with 20% specific efficacy would be swamped by other factors in a trial. This only applies in this case if you are saying that homeopathic remedies as a whole are only 20% effective. This contrasts with the usual claims of homeopaths who say that, given the correct remedy, homeopathy is highly effective.
January 7, 2008 at 10:24 am
Wrong. For 2 reasons.
1) a significant majority of trials of homeopathic remedies show effect beyond the placebo comparison group. The remedy does not “do nothing”. The effect is not as solid an effect as would be statistically conclusive, but this has a lot to do with studies being underpowered.
2) in trials of individualised homeopathy, the ‘placebo’ group are subject to treatment effect resulting from the practitioner’s remedy selection decision, therefore the placebo group you’re using for comparison is not a ‘true’ placebo group for testing the therapy.
Suppose you have a pharmaceutical intervention that depends for its full effect on the synergistic action of 2 drugs. If you want to test the efficacy of the intervention, as opposed to the drugs individually, then you wouldn’t run a trial with your treatment group compared to a ‘placebo’ group that were being given placebo for one half of the treatment and verum for the other.
This is, in effect, what seems to be happening in trials of homeopathy and other complex holistic interventions. Because of the higher degree of non-specific elements in the total treatment effect, your placebo group is heavily tainted with verum. It’s consequently inappropriate to make judgements about the whole therapy on the basis of trials of the effect of only one component of it.
This depends on how you define the placebo effect. If all you’re trying to rule out here is the effect of the patient’s belief they’re receiving something genuine, then employ some good professional actors for your faux practitioners.
If you consider that the placebo effect contains the impact on the patient of the practitioner’s treatment decision, then obviously it’s a different matter, but that effect is a valid part of your therapy and can’t be discounted. The trial data merely tells you about the specific effect of one component of the therapy. It is NOT telling you that the whole therapy is ineffective.
The assumption being employed to arrive at that conclusion in respect of homeopathy is that the impact on the patient of the practitioner’s treatment decision is the same for both biomedical and homeopathic interventions. There’s no basis for that assumption if you’re comparing therapies that work by completely different mechanisms, particularly if you’re comparing generalised therapies with individualised ones.
This assumption effectively dictates that any therapy which is not based on a large specific effect contained in some discrete entity like a pill is “ineffective”. That’s an inappropriate assumption given the weight of case history suggesting otherwise. This is what I mean when I say it’s inappropriate to test CAM therapies on the assumptions of the biomedical model.
January 7, 2008 at 11:01 am
Apologies, John. That’s clear from your protocol. But you’re still only measuring the effect of the remedies alone, not the therapy as a whole, so all my comments on that score still apply. Also, you would likely have huge ethical problems in randomising one group to placebo for this length of time.
Clinical studies have already been performed tracking people’s satisfaction with homeopathy over long periods in treatment. Yes, there are no controls, but you’re unlikely to get people saying they’re satisfied with treatment over that period if it’s done nothing at all for them. The numbers coming in so far suggest that around 70%+ are happy, including those suffering serious chronic complaints. Some trials have suggested people are more satisfied with homeopathy than conventional treatment.
It would be good to have some more large long-term studies, but homeopathy is a minority therapy at present. That’s just a simple fact. You’re not going to be able to recruit people to trial it if you’re simultaneously trying to tell everyone it doesn’t work and that people shouldn’t use it, so it seems rather disingenuous of sceptics to continually complain about underpowered trials when they’re doing their level best to hound the therapy out of existence.
No I’m not saying that. The administration of the remedy does have an effect, as the trial data already suggest, but the practitioner’s decision is also a significant factor, and, because of the specific individualised nature of the treatment, it’s a larger effect than would be the case for a pharmaceutical intervention prescribed on purely generalised considerations.
Given the correct remedy, homeopathy as a treatment is highly effective, but that still doesn’t necessarily mean that the specific effect of the (physical) remedy is huge. Look at Walach’s graph again, particularly at the difference between the 2 placebo groups in treatment x and treatment y. What the graph illustrates is a reasonable generalised comment on homeopathy vs biomedicine. A 20% specific effect is still a 20% specific effect, so the remedies are not ineffective in themselves. They just don’t carry the entire treatment.
January 7, 2008 at 2:30 pm
I know you’ve said that remedies are only a part of homeopathic healing but I would still like to question a few things.
“The administration of the remedy does have an effect, as the trial data already suggest
I’m sorry but I don’t see how you can claim this is the case. To do so contradicts what both you’ve said above, your quotes of Walach and homeopaths’ appeals to faux-quantum theory. While a few trials may have reported to have shown an effect the overall evidence base from trials for homeopathic remedies is extremely weak.
Walach’s attempts to explain why this might be so also don’t hold water. The power of an effect does not soley determine the significance of a test of that effect. Consider a very slightly biased coin (un underpowered effect). Toss it ten times and you could well end up with 5 heads and 5 tails. Clearly this trial is unable to identify the effect of this bias. If, however, you repeat the test using more than 10 tosses the chance of finding an effect is increased. The reverse is also true. A completely fair coin (a non-existant effect) could well result in 7 heads and 3 tails from 10 tosses.
This is why to identify small effects larger and better designed trials are required. However you seem to think doing so is invalid:
“There is an effect beyond placebo in a significant majority of trials (before you start meta-analysing them down to a bare handful that meet your “quality” criteria), but it’s not as strong or reliable as you would expect from a pharmaceutical intervention. That’s only to be expected if the localised hypothesis doesn’t obtain (per Walach above).”
January 7, 2008 at 4:45 pm
“2) in trials of individualised homeopathy, the ‘placebo’ group are subject to treatment effect resulting from the practitioner’s remedy selection decision, therefore the placebo group you’re using for comparison is not a ‘true’ placebo group for testing the therapy.”
The main bugbear of the Bad Science group is that the homeopathic vera are nothing more than inert substances. We’re not looking to test the consultation - we’re only looking for evidence that the vera work above and beyond control. If it turns out to be the case that the vera don’t contribute to the therapy’s success then it begs the question ‘why on earth use them!’
I would still like to see a trial set up with the dummy procedure - this way the effect of the consultation and the effect of the verum can be identified.
January 8, 2008 at 9:01 pm
Not at all. Go back to my 2-drug analogy. If you have an intervention that depends for its full effect on the synergistic action of 2 drugs, then you’re going to see something similar to what we’re seeing here. Test either drug on its own and you’ll likely get a weak positive, but insufficient to be considered demonstrably effective on its own. Give them together and it’s a different story.
I disagree. The coin analogy is a good one for results predicated on a single variable that relies on chance alone, but it’s not a particularly good one here. There’s quite a bit of difference between the toss of a coin and the application of a complex verifiable method to the healing of a specific instance of disease in a human being (or animal) which has proved itself over the course of 200 years in a multitude of individual cases. Whether or not you believe homeopaths to be operating a ritual delusion based on your own assumptions about the ‘impossibility’ of the therapy, the method is demonstrably replicable. And it’s demonstrably replicable in children and animals too.
However, you’re absolutely right in one respect. If you were relying on trial data alone, your conclusions about homeopathy would be entirely reasonable. However, homeopaths don’t come at this from the perspective of the trial data alone. There’s the small matter of that 200 years’ worth of well-documented case history. I’ve argued in some depth exactly why I believe it’s completely inappropriate to regard such data as “invalid”, so I won’t go into that again, but when you observe the reactions practitioners do on a daily basis there really isn’t much room for doubt that there is something in the homeopathic process that is capable of instigating highly effective and permanent cure in people suffering all kinds of conditions, many of which are serious and non-self-limiting, and which have not responded to any other kind of therapeutic intervention.
We therefore tend to approach the trial data from a different angle, and ask a lot more questions about the assumptions on which trial designs and conclusions are based. The thing is though, we could have this discussion for another 200 years and still be no nearer resolution because for every questionable subjective assessment I make you that you can pick holes in, I can do exactly the same to yours. At some point we have to accept that some subjectivity is inevitable and adopt a more pragmatic approach to determining what’s going on, taking the full body of evidence into account.
Not invalid as such, John, just unlikely to provide us with clear answers. All data says something, the problem is in working out exactly what. To get clear answers you have to ask the right questions. You’re not going to get clear answers from homeopathy by asking questions based on the assumption it works like biomedicine does, because it doesn’t — which is obvious.
And realistically it’s going to be very hard to get larger and better trials while the Goldacre-Colquhoun-Baum-Ernst-Egger-Horton et al bandwagon is motoring its way through the administrative corridors of PCTs demanding an end to homeopathy on the NHS and threatening the future of the homeopathic hospitals in this country. Neither has it been easy to access funding.
So what do we do in the meantime? This is why researchers have been studying the therapy as it’s practiced. And if it’s as effective as these studies suggest, and patients are as happy with it as they appear to be, then this constitutes a pretty strong argument for its continued inclusion in NHS services, particularly in the light of the vast number of problems people are experiencing with conventional treatment.
January 8, 2008 at 9:10 pm
The Bad Science group presume that homeopathic vera are nothing more than inert substances because they appear to contain no biochemically active ingredient. There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.
See my answers to John for the issue of verum contribution to overall efficacy. The simplest answer is that remedies are used because they’ve been part and parcel of an empirically derived process which has demonstrated efficacy through 200 years’ worth of case history. You can still get an effect if you take them out of the equation, but it generally tends to be a much stronger and longer-lasting effect if you leave them in.
Do you mean as I suggested with the 3 separate groups, rM, S and D? Yes, I’d like to see that too.
January 9, 2008 at 7:43 am
“there really isn’t much room for doubt that there is something in the homeopathic process that is capable of instigating highly effective and permanent cure in people suffering all kinds of conditions, many of which are serious and non-self-limiting”
Which brings us round to that old chestnut (all together now):
Please provide an example of one, you only need one, incontrovertible example, with references, of homeopathy curing a non-self-limiting condition?
January 9, 2008 at 11:27 pm
I think there’s been more than a few people posting on these blogs who’ve attested to that in their own individual cases. You (in the plural) still manage to suggest their conditions were somehow ’self-limiting’ or that ’spontaneous remission’ is not beyond the bounds of possibility.
No ‘cure’ is incontrovertible for the simple reason that every individual has a lot more going on in their lives than the medication they take for their problems, so it’s always conceivable that their improvement owes nothing to the treatment they received. That’s every bit as true for biomedical treatment as it is for homeopathic. But it’s interesting how the assumption is that improvements under biomedical treatment ‘must be’ a result of the treatment, while improvements under homeopathic treatment are ’spontaneous remission’, ‘natural cessation of non-self-limiting conditions’, etc, etc. There’s plenty of clinical observational data showing improvements under homeopathy for patients who’d experienced no relief at all through pharmaceutical interventions, yet that’s still dismissed as ‘no evidence’.
You see what you want to see M. The evidence is all there. There’s 200 years’ worth of published case history. It’s all there for the checking. Just go look up any of it. You can speculate to your heart’s content about possible alternative mechanisms for every one of these hundreds of cases, but when you take the cumulative case history of cured cases for any one remedy and look at the common threads running through them (which is the basis for homeopathy’s replicability and predicatability), then most rational people would conclude that there’s a good chance the treatment has something to do with it.
January 13, 2008 at 3:13 pm
[...] "What do you think? Could it work and, if not, why not?" Solid. Similar thread over at laughingmysocksoff - though verbose. The problems with clinical trials of CAM: a case of wholly holey socks? Laughing my socks off …… [...]
January 14, 2008 at 1:24 am
[blockquote]I think there’s been more than a few people posting on these blogs who’ve attested to that in their own individual cases. You (in the plural) still manage to suggest their conditions were somehow ’self-limiting’ or that ’spontaneous remission’ is not beyond the bounds of possibility.
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A clear case complete with proper clinical/chemical diagnosis and proper clinical/biochemical outcome is required for this one case which if successful would give homeopathy a boost if nothing else. But none are forthcoming.
Many homeopaths have performed double blind studies but the better ones show homeopathy no different from placebo. Your conclusion that such studies are inappropriate only comes after the results. When shown that such studies can test your precise hypothesis you have retreated further and are now saying that the sugar pills are not the main part of the treatment. I presume you have written to Holland and Barratt and also Boots to tell them of this.
Milgrom’s appalling science as he tries to link particle physics to homeopathy is about the same standard as his papers on showing a physical difference between homeopathic preparations and the diluent. There is a difference between these two attempts, in the latter one he was supposed (and didn’t) know what he was doing. His misuse of mathematics in the former is just laughable.
When homeopathy started it had one great advantage over the accepted theories of the day. It didn’t do anything! This was preferable to blood letting and use of emetics and laxatives on ill patients. But since that time, homeopathy still does nothing. Through proper application of scientific methods and research a wide variety of treatments are available for diesease states that were incurable only 50 years ago. Modern science has achieved these aims by attempting to find out exactly what is happening. It does this by experimentation and measuring the results against the current theory. It didn’t get there by woolly minded thinking, appeals to authority and antiquity or postmodernistic claptrap about metaphors.
After 200 years homeopathy has not provided a convincing clinical trial, any theory about homeopathic preparations which does not break at least one of the theories around which science is based or any provable internal logic on the basis of homeopathy.
January 14, 2008 at 9:36 am
And the ones which are objectively (i.e. for everybody, controlling out their subjectivity) more congruent for certain circumstances are more “right”. If I do a measurement such that everyone can see the same number on the display of the meter, then that’s an objective result.
A metaphor can be applied to a situation in which it is no longer valid, such that at best there is no insight into the situation and at worst the metaphor is actually misleading. Those who understand what was behind the metaphor in the original situation, and therefore understand the limits of its applicability, need to point this out.
But if you’re going to use it, either do it properly or admit you are just exploiting the spookiness and the general lack of understanding amongst your readership to write impressive-looking science fiction. Milgrom doesn’t seems to know or care about the difference between a state and an operator, or between the existence of a state and the occupation of it.
http://link.aps.org/abstract/PRE/v61/p4194
http://arxiv.org/abs/0705.1232
Because the results were just the same before quantum mechanics was invented, which was why quantum mechanics had to be invented to explain them. There’s nothing special about conciousness in quantum mechanics. The Copenhagen interpretation has been superseded.
So omega-completeness is irrelevant to anything which isn’t a formal and consistent mathematical system.
“Does homeopathy work?” is an objective question.
January 15, 2008 at 2:06 am
Then you’ll need to make this request of medically qualified homeopaths. Non-medically qualified homeopaths in this country are not going to have the supporting evidence you require in their possession. This will be held by the patient’s GP or specialist.
I’ve said this many times, but continuing to repeat that mantra isn’t going to make it true. The trial data is equivocal. And what are frequently regarded as “better” trials are judged “better” because they conform more closely to biomedical criteria for quality — ie. they have high internal validity. Most of these don’t come anywhere close to representing homeopathy as it’s practiced, so are not an appropriate trial of the therapy.
As Peter Fisher writes:
The conclusion that trials are inappropriate comes after the results for the simple reason that nobody yet knows how homeopathy works! Trialling the remedies as distinct from the therapy as a whole shows that the full effect does not reside in the remedy alone, ergo we conduct different types of trials to try and elucidate the mechanisms at work. That’s hardly a ‘retreat’. That’s just the process of scientific investigation.
Your conclusions, on the other hand, appear to be based solely on the premise that homeopathy is impossible. That’s putting the theory above the empirical data. Not good science.
That’s pure supposition on your part. Where’s your evidence for that?
Modern biomedical science ignores pretty much anything outside the physical realm and employs a narrow linear logic in developing its interventions with the result that the side effects of treatment can become more debilitating than the original condition. Thousands of people die annually, many unnecessarily, as a result of this logic and countless more have their quality of life severely reduced. Some of the worst of these interventions — cytotoxic chemotherapy for instance — have been shown to have only minor impact on outcomes.
People are voting with their feet in huge numbers. It seems they’d far rather take their chances with ‘unproven’ CAM therapies based on a friend or relative’s recommendation (ie. anecdotal evidence) than they would with the ‘authoritative’ results of clinical trials. Could that be anything to do with the fact that 20% of drugs have to be recalled after passing clinical trials? Or maybe it’s just the experience people have with drugs that have passed these trials failing to do what they’re supposed to? Or perhaps it’s the fact that their feelings about their illness are dismissed as irrelevant, or worse, they’re told to go home and stop wasting NHS resources because no organic cause has been found for their symptoms?
Don’t let your love affair with the theory blind you to what’s going on in the real world. Biomedicine has its limitations. Objectification has its limitations. And attempting to dismiss the fundamentally subjective and self-referential nature of all human theories as ‘postmodernist claptrap’ doesn’t change the fact that all our theories are ultimately subjective and self-referential.
What laws are being broken here? I don’t see any existing theories being invalidated by homeopathy. Only the need for our knowledge to be extended to take into account more subtle non-specific mechanisms we’ve largely ignored up to this point. Newtonian physics wasn’t invalidated by quantum mechanics. It was just shown to be a reasonable approximation within certain parameters. Why should it be any different for biomedicine? You don’t even need homeopathy to see that there’s an awful lot in the sickness and health arena that biomedicine fails to take into account. It’s blazingly obvious.
January 15, 2008 at 4:16 pm
Are they? Or are they simply congruent with what’s common, rather than what’s individual? Just because we have characteristics in common and characteristics which are idiosyncratic, doesn’t make our shared characteristics ‘right’ and our idiosyncratic ones ‘wrong’. This is a wholly unsupportable judgement and one which, IMO at least, has led biomedicine right up its own backside. Taking that logic outside its usual parameters, you’re immediately judging any highly individualised expression — exceptional artistic ability, for instance — as ‘wrong’. The fact that we don’t do this shows the double standards operating. The double standards can only continue to operate provided we maintain an artificially rigid and fragmented approach to human knowledge, art vs science, etc. Many would argue this is precisely why we’re in the trouble we’re in today.
As David Bohm wrote (in Wholeness and the Implicate Order, 1980) in respect of our tendency to objectify the world into separately existing fragments:
What is congruent for any circumstance depends entirely on the nature of the circumstance. The experience of illness is every bit as individual and subjective as it is common and objective. To base your metaphor, diagnosis and treatment entirely on what is common to the majority of sufferers (controlling out their subjectivity) is to leave a large percentage of the relevant data out of consideration. Not only does this compromise the congruence of your operating metaphor, but in circumstances where the individual subjective nature of the illness has far more bearing on its nature and severity than any underlying common factors, then you’re leaving out the data on which the entire case hinges.
That depends on the sense in which you’re using the word ‘objective’. If you mean not influenced by personal feelings and opinions (as opposed to consensus feelings and opinions), then yes, it’s objective. If you mean not dependent on the mind for existence, then no, it’s not objective, because human minds decided on the measure, the principles behind how and why the measurement is being made, and the design and manufacture of the instrument doing the measuring. And human minds are reading the results off the meter and feeding that into their interpretation of what the measurement is measuring. We cannot separate ourselves and our fundamental assumptions about the nature of existence from anything we participate in.
By its nature, a metaphor is an “as if” analogy. The circumstances in which it’s valid aren’t necessarily restricted to contexts in which it can be used quantitatively with precision. In contexts where there are far too many variables to attempt any kind of quantitative use, then its qualitative dimension comes into play. Those who understand what was behind the metaphor in the original situation and who are accustomed to using it quantitatively, precisely, and within a restricted and specific context may not always be best placed to appreciate its wider qualitative applicability. Although many do — it’s clear from the number of physicists writing on the subject that not all feel the same way about the limitations of the metaphor as you and Andy do.
As far as I’m concerned, and from what I know of Lionel Milgrom, there is no intent to exploit, only to attempt to derive a theoretical framework which might explain the empirical observations. This is no more than scientific method. (I can’t speak f